"I may not be able to do anything more to the patient to that will make them survive," says Linda Smith, a palliative care doctor. "But there's a lot more that I can do. I can always do more."

Mark Meyerfor NPR

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Originally published on July 8, 2013 6:51 am

Dr. Linda Smith walks into a room at Providence Alaska Medical Center, ready with a stethoscope and a huge grin. She teases her patient, Dawn Dillard, saying that her spiky hair recently resembled a "faux hawk."

Dillard found out she had uterine cancer a year ago. Her oncologist gave her a year to live. The 57-year-old has beaten those odds, but now her kidneys are failing. After the laughs are over, Smith sits down on the edge of Dillard's bed, leans in, and starts talking about a procedure Dillard will have.

Smith is a palliative care doctor, a specialty that is growing rapidly in the U.S. The idea is to help patients cope with a terminal or life-altering illness. And unlike hospice care, it is not offered only in the final months of life. Smith works on pain management, coordinating care and even does some counseling. Dillard, for one, really appreciates it.

"I can't even say how much she's helped me," Dillard says. "Just little things. You know, showing me things like breathing techniques. Sort of like mediation, just ways to focus on things that are positive and happy rather than focusing on your sickness and how crappy you feel."

Two years ago, Linda Smith was a very different kind of doctor.

She worked in the emergency room at the busy Anchorage hospital, where the goal was to quickly stabilize a patient and move on. But two decades into her career, she started to question how she was caring for patients at the very end of their lives. She remembers putting patients on breathing tubes and hearing family members say things like, "I know Dad didn't want this, but we're just not ready to let him go."

"I started to have a lot of regret about doing things to people that were painful and uncomfortable and were prolonging their suffering," Smith says. She thought, "if I only had the time to sit down with the family, I probably wouldn't be doing these things."

In 2011, Smith enrolled in a one-year palliative care fellowship at Providence. She had a lot to learn. She was a bad listener. And she was abrupt. As an ER doctor, sometimes she was so busy she didn't even sit down to deliver devastating news.

"I can remember saying to families things like, 'I'm sorry, there's nothing more I can do.' And I realize now that sounds like abandonment to many people when you say you can't do anything more. And the reality is I may not be able to do anything more to the patient that will make them survive, but there's a lot more that I can do. I always can do more."

A lot of what Smith does is talk to people. She doesn't advocate for or against treatment, but she wants patients and their families to understand their decisions.

If a doctor puts in a breathing tube, for example, that may extend a patient's life, but they won't be able to eat or talk. If they die with a tube in, the family will miss hearing their last words. So now Smith sits down for hard conversations and looks patients and their family members right in the eye. Earlier this year, she was called in to consult with the wife of a patient who was dying.

"When I entered the room," Smith says, "The wife said to me, 'I know who you are.' And I said, 'Oh. OK.' And she said, 'I don't want to talk with you and I don't want to like you because you're here to talk about death and dying, aren't you?'"

Smith had a short conversation with the woman, and left her a book on difficult end of life choices. She went back to visit her the next day.

"And she said, 'You know, I so tried not to like you. And what you had to say. And I really realize that we need to have this discussion now, don't we?'

There's a shortage of doctors who provide palliative care, and the need is growing as baby boomers slide toward old age.

Smith was planning to go back to the emergency room. But interactions like that one persuaded her to stay in palliative care. Now she works more and makes less money. Some days, she wonders if she's crazy.

But then she gets to visit a patient like Dawn Dillard.

Back in her hospital room, Dillard and Smith talk about having a second procedure. Smith leaves and calls Dillard's other doctors. They end up agreeing that the second procedure isn't really necessary after all. So instead of staying another night in the hospital, Dillard is back home by the end of the day.

Here's a story about a doctor who didn't feel good about who she had become and decided to change it. Linda Smith left a busy, high-paying job as an emergency room doctor. She stayed at the same hospital in Anchorage, Alaska, but she took up a new specialty. It's called palliative care. Its goal is to improve the quality of life for people with chronic or terminal illnesses. And it's a specialty that is growing rapidly in the United States.

Alaska Public Radio Network's Annie Feidt has this profile of Dr. Smith.

ANNIE FEIDT, BYLINE: Dr. Linda Smith walks into a room at Anchorage's Providence Hospital, ready with a stethoscope and a huge grin. She teases about her patient's spiky hair.

DR. LINDA SMITH: Hey, where's the Mohawk?

DAWN DILLARD: How's it going?

SMITH: You got it all gelled down.

DILLARD: I do.

(LAUGHTER)

SMITH: Looks good.

DILLARD: Just so you couldn't make fun of me today.

(LAUGHTER)

FEIDT: Dawn Dillard found out she had uterine cancer a year ago, on her 56th birthday. She's in the hospital now because her kidneys are failing. Smith perches on the edge of Dillard's bed, leans in, and starts talking about a procedure Dillard is scheduled for.

SMITH: Did they talk to you about whether or not you'd be able to go home today if you had it done?

DILLARD: No. No. One of the nurses - I said this morning, I said, I think I'm getting to go home today. And she was, oh, I don't think so.

FEIDT: Smith is a palliative care doctor, a specialty that is growing rapidly in the U.S. The idea is to help patients cope with a terminal or life-altering illness. And unlike hospice care, it isn't offered only in the final months of life. Smith works on pain management, coordinating care, and even does some counseling to improve her patients' quality of life, which Dillard really appreciates.

DILLARD: I can't even say how much she's helped me. There have been just little things. You know, showing me things like breathing techniques, just ways to focus on things that are positive and happy rather than focusing on your sickness and how crappy you feel.

FEIDT: Two years ago, Smith was a very different kind of doctor. She worked in the ER for two decades, where the goal was to quickly stabilize a patient and move on. She remembers putting patients on breathing tubes and hearing family members say things like, I know Dad didn't want this, but we're just not ready to let him go.

SMITH: And I started to have a lot of regret about doing things to people that I thought were painful and uncomfortable and were prolonging their suffering. And if I only had the time to sit down with the family, I wouldn't probably be doing these things.

FEIDT: In the summer of 2011, Smith enrolled in a one-year palliative care fellowship at Providence. It wasn't easy at first. She had a lot to learn. She was a bad listener.

SMITH: I can remember saying to families things like, I'm sorry, there's nothing more I can do. And I realize now that that sounds like abandonment to many people when you say: I can't do anything more. And the reality is I may not be able to do anything more to the patient that will make them survive, but there's a lot more that I can do. I always can do more.

FEIDT: A lot of what Smith does is talk to people. She doesn't advocate for or against treatment, but she wants patients and their families to understand their decisions. If a doctor puts in a breathing tube, for example, that may extend a patient's life, but they won't be able to eat or talk. If they die with a tube in, the family will miss hearing their last words.

So now, Smith sits down for hard conversations and looks patients and their family members right in the eye. She recalls a conversation earlier this year when she was called in to consult with the wife of a patient who was dying.

SMITH: When I entered the room, the wife said to me, I know who you are. And I said, oh, OK. You know? And she said, I don't want to talk to you. And I don't want to like you because you're here to talk about death and dying, aren't you?

FEIDT: Smith had a short conversation with the woman and left her a book on difficult end of life choices. She went back to visit the next day.

SMITH: And she said, you know, I so tried not to like you and what you had to say. And I really realize that we need to have this discussion now, don't we? And I said, when you're ready, we're ready to have that discussion. And she said, I'm ready now.

FEIDT: Smith works more and earns less money than she did in the ER. Some days, she wonders if she's crazy. But then she gets to visit a patient like Dawn Dillard. Back at her hospital room, Dillard is asking Smith if she really needs to have yet another procedure.

I bet it bites to have two procedures, right?

DILLARD: Yeah. Yeah, I would have preferred one.

SMITH: Yeah.

FEIDT: Smith leaves, calls Dillard's doctor and, together, they decide the second procedure isn't really necessary. So instead of staying another night in the hospital, Dillard is back home by the end of the day.

For NPR News, I'm Annie Feidt in Anchorage.

CORNISH: This piece is part of a collaboration with NPR, Alaska Public Radio Network and Kaiser Health News. Transcript provided by NPR, Copyright NPR.